How should I manage an 11-year-old child with hallux valgus (bunions) affecting both the medial and lateral aspects of the first metatarsophalangeal joint?

Management of Pediatric Hallux Valgus in an 11-Year-Old

Conservative management with appropriate footwear modification is the definitive first-line treatment for an 11-year-old with bunions, and surgery should be avoided until skeletal maturity due to high recurrence rates in children. 1

Initial Conservative Approach

Footwear Modifications (Primary Treatment)

• Switch to shoes with a wide toe-box, soft uppers, and extra depth to accommodate the deformity and prevent progression. 2, 3
• Refer for specialized footwear if standard shoes cannot accommodate the deformity or if there are signs of abnormal loading. 2
• Avoid tight-fitting shoes at the metatarsophalangeal joints, as constrictive footwear accelerates hallux valgus progression and creates friction and pressure. 2, 4

Additional Conservative Measures

• Apply accommodative padding over bony prominences to relieve pressure from the medial bunion. 3
• Consider custom pressure-relieving orthoses if standard padding is insufficient. 3

Clinical Examination Priorities

Key Assessment Points

• Inspect for complications including corns, calluses, or skin breakdown over the medial eminence where the bunion contacts shoe surfaces. 3
• Examine for coexisting deformities that commonly occur with hallux valgus: metatarsus adductus, equinus contracture, hammertoe deformity, and pes planus. 5
• Assess joint congruency, as nearly all juvenile bunions (98.2%) have an elevated distal metatarsal articular angle (DMAA) and congruent joints, which differentiates them from adult bunions. 6

Understanding the Pediatric-Specific Pathology

Why Surgery Should Be Delayed

• Treatment should remain conservative and surgery avoided until skeletal maturity is achieved due to the high incidence of recurrence in children. 1
• Recurrent deformity occurs in approximately 29% of patients in some surgical series, emphasizing the importance of delaying intervention. 2
• The presence of open growth plates defines this condition and contributes to the plastic nature of the deformity components. 1

Unique Features of Juvenile Bunions

• The elevated DMAA (average 21.4° ± 8.9°) is the defining factor that differentiates juvenile bunions from adult deformities. 6
• The deformity involves lateral deviation and pronation of the hallux, medial deviation of the first metatarsal, and abnormal sesamoid positioning. 7, 5
• Severity of radiographic deformity correlates significantly with worse patient-reported outcomes, with increased second metatarsal head pressure indicating transfer of load. 6

Daily Care Instructions

Patient and Family Education

• Inspect feet daily, including between toes, using a mirror if needed to identify early skin breakdown. 3
• Apply moisturizers to dry skin but never between the toes to prevent maceration. 3
• Emphasize that inappropriate footwear is a major modifiable cause and continued use of tight shoes will worsen the deformity. 3, 4

Surgical Considerations (If Conservative Treatment Fails After Skeletal Maturity)

Timing and Approach

• If surgery becomes necessary after skeletal maturity, any operative procedure must correct all deformity components: pronation of the hallux, increased hallux valgus angle, enlarged medial eminence, increased intermetatarsal angle, and hypermobility of the first metatarso-cuneiform joint. 8
• Functional support with bracing is preferred over immobilization in post-operative management. 2